The New York City Administration for Children s Services and the New York University Langone Medical. Trauma and Parenting

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1 Trauma and Parenting A Practice Brief Introduction A large number of children and youth who enter the child welfare system have a history of multiple and chronic traumas, which can have a profound effect on their psychological functioning. 1 As awareness of their mental health needs has become more widespread, child welfare systems are increasingly making trauma-informed, evidence-based interventions available. 2 What has received considerably less attention is the role of trauma in the lives of parents who are involved in the child welfare system. In recent years, studies have established that many of these parents also experience multiple challenges related to high rates of poverty, childhood abuse, interpersonal violence, and substance and mental health disorders. 34 Parental trauma may profoundly impact both parenting and engagement with the child welfare system. A recent study of mothers reported for child maltreatment shows that depression onset is associated with increased psychological aggression. 5 High levels of depression have also been documented among female caregivers reported for maltreating their children, and the level of depression is significantly associated with the level of interpersonal violence exposure. 6 Additional research suggests that mothers with untreated PTSD may be less able to parent effectively, may be at greater risk of abusing their children and/or may have less ability to protect them from the effects of abuse by others. 78 Of particular significance to the child welfare system is the effect trauma may have on parents ability to engage with service providers. Kemp and colleagues recently highlighted the low levels of service engagement among parents, 3 while elsewhere, untreated maternal trauma was found to be associated with unstable affect and difficulty trusting service providers. 9 The success of child welfare services depends in part on the willingness of parents to work with providers and create a safe home for their children. Despite this, most existing evidence-based interventions available to children in the child welfare system do not directly address issues of parental trauma. 10 What we ve learned in New York City The New York City Administration for Children s Services and the New York University Langone Medical Center have established the, which seeks to use trauma-related knowledge to improve child welfare practice, and to help the child welfare system meet its goals on both the individual client and system levels. To address maternal trauma issues, the Institute established the Safe Mothers, Safe Children project in The project s goal is to reduce the risk of child maltreatment among families receiving child welfare preventive services through identifying and treating mothers with traumarelated disorders, particularly posttraumatic stress disorder (PTSD) and depression. 1

2 The Safe Mothers, Safe Children project consists of four key components: screening, assessment, treatment and treatment adaptation, and training and technical assistance, as described below: Screening. We train preventive services caseworkers on how to screen parents for trauma and related issues, and provide follow-up consultation and technical assistance. Data from the screening protocols documents an extraordinarily high level of trauma exposure and trauma-related symptoms among families receiving preventive services. Assessment. Clients identified through the screening as having elevated PTSD symptoms are offered an assessment to determine their eligibility for our treatment intervention. These measures address PTSD, depression, parenting stress, parent-child conflict, child trauma exposure and other facets of trauma. For those women who enroll in treatment, this assessment establishes baseline data for comparison later in treatment. To date, the clients who have completed treatment no longer meet criteria for PTSD up to three months post-treatment. Treatment and Treatment Adaptation. We are adapting an existing evidence-based PTSD intervention, STAIR (Skills Training in Affective and Interpersonal Regulation), to focus on how trauma impacts parenting. Our model, Parenting STAIR, is the result of a collaboration between the, Marylène Cloitre and Kerry Makin-Byrd at the National Center for PTSD, and Anthony Urquiza, Susan Timmer and Leslie Whitten at the UC Davis PCIT Training Center. (Dr. Cloitre was the original developer of STAIR.) In addition to addressing the mother s trauma history and current trauma symptoms, Parenting STAIR has a focus on the parent-child relationship and a dyadic component that borrows both structure and content from Parent-Child Interaction Therapy (PCIT), an intervention developed by Sheila Eyberg for children with behavior disorders. Parenting STAIR seeks to help mothers understand and manage their trauma symptoms, see how trauma has negatively impacted their relationship with their children and their experience of parenting, and increase the positive relationship they have with their children. Training and Technical Assistance. We have developed a structured training program for child welfare staff that covers topics such as Introduction to Trauma, Engagement and Alliance and Impact of Trauma on Parenting. Additionally, our clinicians offer consultation to caseworkers after each screening conducted, and recommendations to clients and agency caseworkers following each assessment. A National Perspective In light of the recent research indicating the impact of maternal trauma on parenting and service engagement, organizations across the country have begun to develop child welfare-related initiatives that emphasize a trauma perspective. These interventions highlight the role of trauma in the lives of affected families and attempt to strengthen the family unit through a combination of education, coping strategies and family ritual. Here are some examples of this work happening across the country: The Family-Informed Trauma Treatment (FITT) Center, a collaboration between University of Maryland s School of Medicine, University of Maryland School of Social Work and Kennedy Krieger Family Center, puts into prac- 2

3 tice family approaches that promote safety and recovery for families experiencing chronic trauma and stress. FITT has introduced three interventions in this effort: Strengthening Families Coping Resources, which uses family rituals, routines and traditions to support family coping and posttraumatic recovery and growth; Trauma-Adapted Family Connections, which partners with families to develop their skills in ensuring safety in their homes and communities; and FamilyLive, a trauma-focused, intensive family therapy intervention developed by clinicians at the Kennedy Krieger Institute Family Center, which addresses the impact of intergenerational trauma on the adult caregiver s ability to provide safety, predictability and emotional security. In Minnesota, the Ambit Network partners with nonprofit, government, and community agencies to improve care and implement prevention and intervention techniques to increase children s ability to cope with trauma. One of their programs is Parenting Through Change (PTC), an evidence-based parent training program that emerged from the Oregon Parent Management Training interventions (PMTO). PTC teaches core positive parenting practices; Ambit has adapted the program for families exposed to traumatic stress, in order to strengthen traumatized parents capacities to respond to their own and their children s trauma-related emotional reactions. Finally, the National Child Traumatic Stress Network has developed a series of factsheets on parental trauma in the child welfare system for various stakeholders: caseworkers, judges and attorneys, clinicians, resource parents and birth parents themselves. These fact sheets illustrate the impact of parental trauma on parenting and service engagement and provide recommendations for the use of a trauma-informed approach. Special emphasis is placed on the perspective of a traumatized parent and the ways in which trauma history can interfere with communication and collaboration. These fact sheets can be found at resources/topics/child-welfare-system, and other resources regarding family trauma can be found elsewhere on the NCTSN website. Recommendations A trauma-informed child welfare system is one in which policies and practices address the role trauma and violence play in the lives of those interacting with the system. Given the widespread prevalence of trauma among parents in the child welfare system, an understanding of parents trauma history should be integrated into child welfare practice at every level. Based on our experience and what we have learned from colleagues in other jurisdictions, we have developed the following recommendations, which we think will help ensure that parent trauma is addressed: Provide staff with training on trauma and trauma symptomatology. Despite the prevalence of trauma histories among clients of the child welfare system, trauma training is not consistently provided to child welfare staff. Providing information on trauma and its impact on client presentation, program engagement and service outcomes can enhance child welfare staffs ability to ask parents about their trauma histories, recognize trauma symptoms and be more effective in collaborating with and supporting their clients in keeping their children safe. Provide trauma screening for parents. Research has shown that parental trauma can have as much of an impact on child welfare outcomes as child trauma. Screening parents for trauma as part of routine practice can significantly increase caseworkers ability to fully understand their clients behavior and related challenges, and 3

4 foster an environment focused on cooperation, understanding, trust and hope which increases the likelihood of children staying with or returning to their parents. Facilitate cross-system communication. Our Safe Mothers, Safe Children model includes a collaborative relationship between caseworkers and mental health providers, which allows for communication about areas of improvement and those where the client continues to struggle. This collaboration helps to engage clients, creating a positive and safe environment and motivating them to see the treatment to completion. We believe that this kind of integrated approach with mental health services could benefit all aspects of the child welfare system. Ensure that practice models are trauma-informed. Implementing trauma-informed child welfare practice is both a top-down and bottom-up process. As important it is for child welfare staff to address trauma on an individual basis, the child welfare system as a whole must support these individual efforts. We suggest that through research, on-the-ground training and system-wide initiatives, trauma-informed practices can help to engage clients with histories of trauma and violence, and improve safety, permanence, well-being, adoption stability and other child welfare system outcomes. Acknowledgements Funding for this work was provided through the Substance Abuse and Mental Health Services Administration s National Child Traumatic Stress Network. Thanks to Peggy Ellis, Charles Barrios and Liz Roberts from the New York City Administration for Children s Services for their collaboration and support. Special thanks to Elizabeth Thompson from the Kennedy Krieger Center, Laurel Kiser from the University of Maryland, and Abigail Gewirtz from the University of Minnesota AM- BIT Network for providing information to us about their important work. Recommended Citation. (2012). Trauma and Parenting: A Practice Brief. New York: NYU Langone Medical Center. References 1 Kisiel, C., Fehrenbach, T. Small, L. & Lyons, J.L. (2009). Assessment of complex trauma exposure, responses, and service needs among children and adolescents in child welfare. Journal of Child & Adolescent Trauma, 2(3), Landsverk, J., Garland, A., Reutz, J.R. & Davis, I. (2011). Bridging science and practice in child welfare and children s mental health service systems through a two-decade research center trajectory. Journal of Social Work, 11(1), Kemp, S., Marcenko, M., Hoagwood, K. & Vesneski, W. (2009). Engaging parents in child welfare services: Bridging family needs and child welfare mandates. Child Welfare, 88(1), Marcenko, M.O., Lyons, S.J. & Courtney, M. (2011). Mothers experiences, resources and needs: 4

5 The context for reunification. Children and Youth Services Review, 33, Conran, K.J., Beardslee, W., Koenen, K.C., Buka, S.L., Gortmaker, S.L. (2009). A longitudinal study of maternal depression and child maltreatment in a national sample of families investigated by child protective services. Archives of Pediatrics and Adolescent Medicine. 6 Hazen, A.L., Connelly, C.D., Kelleher, K., Landsverk, J., Barth, R. (2004). Intimate partner violence among female caregivers of children reported for child maltreatment. Child Abuse & Neglect, 28, Banyard, V.L., Williams, L.M., Siegel, J.A. (2003). The impact of complex trauma and depression on parenting: Exploration of mediating risk and protective factors, Child Maltreatment, 8(4), 4, Cohen, L. R., Hien, D.A. & Batchelder, S. (2008). The impact of cumulative maternal trauma and diagnosis on parenting behavior. Child Maltreatment, 13(1), Dawson, K. & Berry, M. (2002). Engaging families in child welfare services: an evidence-based approach to best practice, Child Welfare, 81(2), Department of Psychiatry New York University Langone Medical Center New York, New York June

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